Appendix 2

Return to Work Plan and Return to Work Interview Form

Part 1: Record of Absence

Part 2: Return to Work Plan

Part 3: Return to Work Interview

Instructions for completion: Line Managers must complete every section. ‘N/A’ should be recorded where no actions are required - this is to confirm that actions have been considered.

Part 1: Record of Absence

To be completed by Line Manager/Supervisors/Administrator etc. at the time of receiving notification of absence.

Employee’s name
Job Title
Team/Location
Date/time notified of absence
Dates of absence / Reason for absence
Please note: if the reason for absence is likely to result in a number of days absent and/or is due to a musculo-skeletal-related illness, stress, mental health concerns, bullying and harassment, workplace incident etc. the employee should be advised that the line manager will be in contact shortly to discuss support for returning to work (see Part 2) / Employee’s contact number (for line manager to contact, where required and to enable discussions on a return to work plan).

Part 2: Return to Work Plan

This section MUST be completed – please state if no action plan necessary

  1. Actions to support return to work/address reason for absence
  1. Review date:

Guidance for Line Managers/Supervisors: To support a return to work, Line Managers may discuss and consider the following with the employee (please note, the suggested support is not exhaustive. Identifying specific supportive measures will be through discussions with the employee):
  • a stress, depression or musculo-skeletal related illness, regardless of the duration of absence, then consider whether to refer to Occupational Health immediately, and you may take advice from HR about this.
  • For stress and depressive illnesses - supportive measures such as stress risk analysis and follow-up action plan (see the Trust’s Managing Stress and Enhancing Wellbeing Policy and Procedure), management referral or self-referral to the Employee Assistance Programme or sign posting to other internal Health and Wellbeing Services such as the Recovery College and Critical Incident Stress Management (see website for current information).
  • For an alleged bullying and harassment issue – follow the Bullying and Harassment Policy and Procedure

Part 3: Return to Work Interview

1 / Date employee returned to work? / ______
2 / Date ‘Return to Work Interview’ completed?
Was the ‘Return to Work Interview’ held within 24 hours of the employee’s return to work?
If NO, please state the reason the ‘Return to Work Interview’ was delayed? / ______
Y / N
1 / Is the employee fully recovered and fit to return to duty?
If YES, discuss whether a "fit note" has been received to confirm fitness to resume work, and note any adjustments needed to enable a return on the Action Plan.
If NO, discuss and confirm next steps on Action Plan overleaf, to include any adjustments needed to work area, equipment etc. to support the return to work. / Y / N
2 / Discuss details of previous 12 month’s sickness as outlined below or by referring to the ‘Informal Sickness Absence Monitoring Record (continue on a separate sheet if necessary):
Inclusive Dates / No Days off / Reason
Has the employee hit the Trust’s Triggers for sickness absence?
  • 5 or more occasions in 12 months
  • 3 or more occasions in 6 months
  • 21 days continuous absence
If YES, discuss and confirm next steps on Action Plan overleaf. / Y / N
3 / Does the employee consider the reason for this episode of absence is work-related? (i.e. caused or exacerbated by work duties)
If NO, go to Question 4. / Y / N
3a / Was it appropriate to complete an incident form (Safeguard) and / or a RIDDOR completed and / or Occupational Health notified?
If YES, give details of what was reported, how, by whom, dates and any other relevant information: / Y / N
3b / Does the employee consider the reason for absence is work-related stress?
If YES, please refer to the Managing Stress and Enhancing Wellbeing Policy (Appendix 2 - Guidelines for Managers to Prevent and Reduce Stress. Appendix 3 – Guide for Staff on Personal Stress Management).
If a potential work-related or other stressor has been identified, discuss and detail appropriate actions on Action Plan overleaf (consider referral to Workplace Options, Employee Assistance Programme, 0800 243 458) / Y / N
4 / Is the employee anticipating any future health problems/sickness absence?
If YES, discuss what preventative measures will be taken by the employee and / or what support will be provided by the manager to reduce the potential of further sickness absence. Confirm agreed actions on Action Plan below. / Y / N
5 / Does the employee have any medical appointments planned for the future?
If YES, for what and when? / Y / N
6 / Identify whether the employee has any secondary employment. If YES confirm the following:
•That that they did not undertake such employment during their period of sickness absence (if work has been undertaken, see Appendix 10 ‘Absence and Secondary Employment’- of the Managing Sickness Absence Procedure); and
•That they have recorded their secondary employment on the Trust’s Register of Interests. / Y/N
7 / Update employee on work / team developments

ACTION PLAN

This section MUST be completed – please state if no action plan necessary

Include details of:
  • Supported phased returns e.g.: for staff returning from long term sickness, i.e.: managing adaptions, details of hours and duties of phased return period etc.:
  • Any other changes needed to work area, equipment etc. to support a return to work
Will a further sickness absence episode trigger the formal process (i.e. 3 episodes in 6 months or 5 episodes in 12 month)? If so, please discuss this with the member of staff as part of the plan.
Advise the employee that their absence levels are being monitored under the Managing Sickness Absence Procedure. The Return to Work Interview forms part of the Monitoring Procedure
Review date:
Action plan review (notes):

Declaration by Employee and Manager

I declare that the information I have given on this form is true and accurate as discussed between myself and the manager named below. I understand that it may be a serious disciplinary offence to provide false information at the return to work interview and / or on this form.
I understand this form will be reviewed at any subsequent Return to Work Interviews and as part of the Sickness Absence Monitoring process to monitor agreed actions and sickness absence and may be used anonymously for Audit Purposes.
Employee Signature: /

Manager Signature:

Date signed by Employee: /

Date signed by Manager:

The form is part of the Sickness Absence Monitoring Record and Procedure and must be retained locally by the Line Manager of the employee and securely stored in the employee’s file, where it can be accessed to monitor any further actions / absences during the . A copy of the form should be given to the employee.

Note: Return to Work Interview audits will be carried out across the organisation on a periodic basis so the information on this form may be shared confidentially with Auditors. However, no personal identifiable information will be contained within the Audit Report.

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Return to Work Interview Form

Version 2

January 2015